Late-onset Lennox-Gastaut syndrome: Diagnostic evaluation and outcome

Abstract

Background: We describe the clinical features and outcome in patients with late-onset Lennox-Gastaut syndrome (LGS).

Methods: Adult patients evaluated between January 1, 2000, and March 1, 2017, who presented with onset of LGS ≥10 years were identified. Data abstracted included age at seizure onset, seizure types, etiology, treatments, EEG and neuroimaging results, cerebrospinal fluid (CSF) findings, and autoimmune evaluation.

Results: Ten patients (8 females) were identified. The mean age at onset of seizures consistent with LGS was 16.5 years (range, 10-32 years). Seizure types included tonic, atonic, and tonic-clonic seizures (all), myoclonic seizures (n = 3), and atypical absence seizures (n = 7). Five patients had normal intellectual function at onset. Prolonged video-EEG monitoring recorded seizures and generalized interictal epileptiform discharges in all. All patients had drug-resistant epilepsy (range of antiseizure drugs tried, 7-16). Two patients had a history of intrathecal methotrexate to treat acute lymphoblastic leukemia. Two patients had malformations of cortical development. CSF analysis (n = 5) showed a mild elevation in the protein level without other abnormalities. Autoantibody determinations in the serum (n = 4) or the CSF (n = 5) and genetic testing (n = 5) were negative. At final follow-up, all but 1 patient was disabled and required a caregiver, and none were driving. One patient died of probable sudden unexpected death in epilepsy (SUDEP).

Conclusions: Late-onset LGS represents a rare, treatment-resistant generalized epilepsy that is disabling and may be associated with progressive cognitive impairment. The elevated CSF protein level in our cohort could have been due to high seizure burden but increases the possibility of an inflammatory component to the pathophysiology of this disorder.

Figure 1. EEG with features of Lennox-Gastaut syndrome (LGS)

Generalized paroxysmal fast activity (first arrow) and generalized 2-Hz slow spike wave (second arrow) in a 35-year-old patient with late-onset LGS (patient 1).

Figure 2. Ictal EEG

Generalized high-amplitude sharply contoured slow wave (first arrow), followed by diffuse electrodecremental response (second arrow) in a 35-year-old patient with late-onset Lennox-Gastaut syndrome (patient 1) during an atonic seizure.